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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGt& STORAGE TANK PROGRAM - FARM TANK INFORMAWRM <br /> FACILITY/SITE INFORMATION (Complete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A Lagc, m,, Iso <br /> C ADDRESS (Street address of TANK location) 1 PHONE 1 "'T" AREA cooE <br /> N c� Ycc v4 L16� /a'69 <br /> T CITY STATE LIP CODE NEAREST CROSS STREET <br /> Y — Fu ((ca <br /> CHECK NINE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION L ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 RFCeeVeD <br /> P Alin <br /> ER MAILING or STREET ADDRESS OPERATOR PHONEF�VrR" AREA CODE jq q <br /> A P�NMfIVI <br /> 0 CITY STATE 11P CODE ERVICESA(Ty <br /> R <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION B ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 """ AREA CODE <br /> W <br /> N <br /> E <br /> R CITY STATE 111 CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> Cheek Appropriate box <br /> T ACTIVE FARM TANK SITE (One or sore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> E <br /> PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additicn•l tan: information on separate sheet if needed) <br /> T TANK SITE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K - <br /> I <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME �� TITLE DATE <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGMISUB CODE DATE <br /> EH 13 044 (11/88) <br />